Provider Demographics
NPI:1033659164
Name:ETERNAL DERMATOLOGY AND AESTHETIC CENTER LLC
Entity type:Organization
Organization Name:ETERNAL DERMATOLOGY AND AESTHETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:IFE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-479-6544
Mailing Address - Street 1:11711 E MARKET PL STE 100
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2710
Mailing Address - Country:US
Mailing Address - Phone:301-479-6544
Mailing Address - Fax:301-622-3377
Practice Address - Street 1:11711 E MARKET PL STE 100
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2595
Practice Address - Country:US
Practice Address - Phone:301-479-6544
Practice Address - Fax:240-654-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0071033207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty